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MEDITECH INSTRUCTIONS: 1. Click “Enter New” (on the right-hand navigation menu) 2. Search “Student History & Physical,” add to favorites 3. Click “Add Section” (on the right-hand navigation menu)  search “History & Physical – blank,” add to favorites 4. Copy & paste the template below into the “H&P-BLANK” section of your note 5. Press F2 on the keyboard to tab through all the parts of the history that need to be changed for your individual patient 6. Click “Quick Save” ---- CHIEF COMPLAINT: [] HPI: [] yo G[]P[] at [] []/7 WGA by last menstrual period consistent with [] week ultrasound who presents to labor and delivery triage with []. Patient denies vaginal bleeding []loss of fluids, [] contractions, []reports active fetus Prenatal care complicated by []diabetes []hypertension Patient has been receiving prenatal care with Dr. []. Estimated due date []. OB HISTORY: G1 []year []vaginal or c/s at [] weeks. []Male or female []baby weight []no complications []diabetes, preterm, hypertension, preeclampsia G2 []year []vaginal or c/ at [] weeks. []Male or female []baby weight []no complications []diabetes, preterm, hypertension, preeclampsia G3 []year []vaginal or c/s at [] weeks. []Male or female []baby weight []no complications []diabetes, preterm, hypertension, preeclampsia G4 []year []vaginal or c/s at [] weeks. []Male or female []baby weight []no complications []diabetes, preterm, hypertension, preeclampsia GYN HISTORY: Menses: Age at menarche [], [] regular every month, lasts [] days STDs: patient reports [] no history of STI’s, Abnormal Paps: [] no documented abnormal pap smears, patient denies PMH: []Denies PSH: []Denies FAMILY HISTORY: []No family history of birth defects or genetic disorders. []No breast, uterine, ovarian or colon cancer. SOCIAL HISTORY: [] No tobacco, no alcohol, no drugs during this pregnancy MEDICATIONS: []Prenatal vitamins ALLERGIES: [] ([]rash, []anaphylaxis) ROS: []All systems were obtained and negative except as stated in the above HPI. PHYSICAL EXAM: Vital signs reviewed [] (ENTER “VITAL SIGNS - LAST 24 HR RANGE” AND “VITAL SIGNS - FIRST DOCUMENTED” HERE - click “Data Formats” on right-hand menu & search for these) Gen: []alert and awake HEENT: []normocephalic, no periorbital edema CV: []regular rate and rhythm without murmurs, gallops, or rubs Resp: []clear to auscultation bilaterally Abd: []soft, gravid and nontender Extremities: []no clubbing, no cyanosis, []trace edema on lower extremities Pelvic: []adequate pelvis, EFW[] Cervix: [] Skin: []Normal turgor, no rash Psych: []Appropriate mood and affect Neuro: []AAOx3, CN II-XII intact MEDICAL DECISION MAKING: Prenatal Labs: Blood Type [] Rubella []immune RPR []non-reactive HIV []negative HBV []negative Gonorrhea []negative Chlamydia []negatve 1-hour GTT [] Pap []normal GBS [] External Fetal Heart Rate Monitor: [] baseline HR [] with moderate variability, [] no decelerations Tocometry: [] contractions Bedside U/S: [] [] (ENTER “ALL LAB/MICRO/RAD LAST 16 HRS” AND “CBC-FISHBONE ONLY” HERE – click “Data Formats” on right-hand menu & search for these) ASSESSMENT: 1) [] yo G[]P[] at [] []/7 WGA by LMP c/w [] weeks ultrasound here for []. 2) Active labor 3) Reassuring fetal status 4) Cephalic presentation 5) GBS[] PLAN: - Admit to Labor & Delivery for [] - R/B/A of delivery and blood transfusion discussed and consents signed - Routine labs and IVF - Will augment with Pitocin as needed and tolerated - Epidural PRN - Routine intrapartum monitoring Patient care plan discussed with attending physician Dr. [] and []he/she agrees